9602-106 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
Se9tion 7000) of Division 3 of the Business and Professionals Code, and my
ease is in full force,and effect. i„ i 69
cense # LIC. Class—,ExpDam
Date V t_ Y o Signatureof Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not Intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals Code).
( ) I am exempt under Section , B&P.C. forfhls reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation Insurance, as required by
Section 3700 of `the Labor Code, for the performance of the work for which this
permit is Issued. My workers' compensation insurance carrier& policy no. are:
Carrier Policy No.
(This sectlofi.* completed if the permit valuation%,4WV00.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
1 shall not employ any person in any manner so as to become subject to the
wort erb' compensation laws of California, and agree that if 1 should become
SyL bject to the workers' compensation provisions of Section 3700 of the Labor
kCode, I hall fo with comply with those ions. ,r,...
Date: Y f Applicant "ti t —,
Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
subject an employer to criminal penalties and civil fines up to $100,000, In
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, Interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his application.
1. Each person upon whose behalf this application Is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this application agrees to, & shall, Indemnify
& hold harmless the City of Indian Wells, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of Issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above Information Is
correct. I agree to comply with all City, and State laws relating to the building
con)driuction, and hereby authorize representatives of this City to enter upon the
mentioned property for inspection purposes.
Signesure (Owner/AgerM
ALC "B.
DING PERMIT
PERM
DATE
VALUATION 'v ' LOT TRACT
JOB SITE ADDRESS CHERRY MU, H1IH
APN
OWNER
CONTRACTOR
ZONE
AGC(
17.kafi,/L �. 1�\�
^�J ,' 9.' 9 (' A t r j .I2 STIR. 1
/,` .., 1.!11.11.! ..G 5111.. '..'lew.�
i3-040 PCrA rlTsvcf
T=aI:17.rd+TIDA DUNES CA 02203
LA QUIN'1'A CA 97253
(6t61717 3585
4619)771-1734
DESIONEWENOINEER
USEOFPERrdiTt..r Ptv J vU
,-£;Wi It CONNE(f,Y FOR Cif )f }, (;(/URS11' tutiS't'ttC. ONO
'Note abl"Ve Il1►_nled a voitrwtor W -As also the gela-ml cewil. for i-olim-uCtion of rtrittkorll.
FEE DESCRIPTION
FEES
ANIOUNT 430,00 LS
ESTIMAITT) COST 'OF CONSTRUCT ION
430ml
PERIIMI Il' FEE E SiU f141N3.ARY
PIATNIT,lf.NG FiF .- SE WT -,R IM -000-1194.". 530.00
-�-�-�
u --Ji
CO
0
d
I
SU -TMAL (',0N&1RLrc, ICON ANIS PLAN CHECK
5i3�.Uta
LIESS PR -E -PAID 17T ES
SO.00
TOTA.I. PERMIT FEES DUE NOW
$30.00
RECEIPT
DATE
By
DATE RNALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
. BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms& Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam'
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) `
ELECTRICAI APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: